Severe Left Ventricle Dysfunction Research Articles

A comparison of two approaches for intraoperative levosimendan administration in cardiac surgical patients with severe left ventricle dysfunction

It is proved that levosimendan administration improves overall outcome and reduces mortality in high risk cardiac patients. However up to now there is no optimal scheme of its use in intraoperative settings. To compare two approaches of levosimendan administration in patients with left ventricle ejectionfraction less than 35% who underwent cardiac surgery. After approval by the local ethics Committee, 40 patients older than 18 years with severe preoperative left ventricular dysfunction (left ventricle ejection fraction less than 35%), who were planned for cardiac surgery operation with cardiopulmonary bypass and cardioplegia were randomly assigned to two groups of 20 patients each. In group I (n=20) infusion of levosimendan started intraoperatively after induction of anesthesia, a loading dose of 6 mg/kg with subsequent injection of a dose of 0.1 μg/kg/minfor 24 hours. In group 2 (n=20) bolus of levosimendan 24 μg/kg was injected 15 min before aortic clamping. Anesthesia and methods of cardiopulmonary bypass in the groups did not differ Results. We got thefavorable clinical results in a group of 'full" levosimendan dose (12.5 mg as a daily infusion with an, initial bolus of 6 mg/kg just after the induction of anesthesia) in terms ofreduction of the total dose ofsympathomimetics andpostoperative troponin T level in comparison with the group where levosimendan was administered as a single bolus. (24 mg/kg) 15 minutes prior to aortic clamping. Based on these data it can be assumed that the use of prolonged infusion of levosimendan in a dosage of 12.5 mg is preferable to a single bolus 24 μg/kg.

An Alternative Approach for Very High-risk Non-operative Patients with Severe Aortic Stenosis and Multivessel Coronary Disease - Staged Coronary Angioplasty and Transcatheter Aortic Valve Implantation – Case Report and Review of Literature

The Aim : The management of obstructive coronary artery disease before the transcatheter aortic valve implantation (TAVI) is not yet well established. Presentation of Case: We describe a 68-year-old patient with severe aortic stenosis, multivessel coronary artery disease, severe left ventricle dysfunction and several co-morbidities, who was disqualified from aortic valve replacement concomitant to coronary artery by-pass grafting because of excessive operative risk (logistic EuroScore 27.62%, STS 13.3% risk of mortality). After careful assessment he was treated with staged percutaneous coronary intervention (PCI) of the left main

Iatrogenic reverse takotsubo cardiomyopathy.

A 47-year-old woman with a history of ischemic stroke and dyslipidemia presented with severe gastrointestinal (GI) symptoms that lasted for a week. The abdominal CT was normal, but due to persistent complaints, she was admitted for clinical monitoring. Intravenous β-blockers were administered for a sinus tachycardia. Soon after esmolol, acute cardiac failure ensued with prompt progression to cardiogenic shock. Owing to acute respiratory failure, the patient was mechanically ventilated and inotropes were started. Electrocardiogram showed no signs of myocardial ischemia (Fig. 1), with a slight prolongation of the QTc interval (479 ms). A mild troponin I elevation was detected (8.2 μg/l) and the nt-pro BNP levels were 12 706 pg/ml. Figure 1 ECG after acute heart failure onset. Sinus tachycardia. No signs of myocardial ischemia. The transthoracic echocardiogram (TTE) was performed after the clinical diagnosis of acute heart failure, which revealed a non-dilated left ventricle (LV) with severe systolic dysfunction. Apical segments had a preserved contractility, contrary to the mid-basal ones, which was not supportive of a coronary event. Moderate functional mitral regurgitation (MR) was identified (Figs 2, ​,33 and Videos 1, 2). Video 1 Initial TTE sub-costal view. Non-dilated LV and severe LV dysfunction, normal LV wall thickness, preserved LV apical contractility, and mid- to base akinesis of the LV are indicated. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0009-v1 Download Video 1 Video 2 TTE apical three-chamber view, showing functional MR. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0009-v2 Download Video 2 Figure 2 Initial TTE sub-costal view, end-systolic frame. Non-dilated LV and severe LV systolic dysfunction are observed. Preserved contractility of the apical segments can be noticed (asterisk). Figure 3 Initial TTE apical three-chamber view. Functional MR can be noticed. A coronary angiogram revealed no significant disease and a LV angiogram confirmed severe systolic dysfunction, with MR. Similar to the TTE, a wall motion pattern of preserved apical contractility was recognized (Fig. 4 and Video 3). Video 3 LV angiogram. There is a preserved LV apical contractility, in contrast to the mid- to base akinesis. Functional MR can also be noticed. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0009-v3 Download Video 3 Figure 4 LV angiogram end-diastolic (A) and end-systolic (B) frames. Akinesis of the mid- and base segments of the LV anterior and inferior walls (white asterisks) is indicated. Preserved apical contractility (black asterisks) and MR (yellow asterisks) can also ... The subsequent clinical evolution was excellent. The TTE, performed 72 h after admission, showed a normal LV systolic function with no wall motion abnormalities and no MR (Videos 4 and 5). The nt-pro BNP decreased to 6917 pg/ml. Improvements were also registered two weeks later through cardiac MRI evaluation, and no myocardial edema, fibrosis, or infarction was identified (Fig. 5 and Video 6). Video 4 TTE apical four-chamber view 48 h after heart failure onset, with complete recovery of LV dysfunction and wall motion abnormalities. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0009-v4 Download Video 4 Video 5 TTE apical three-chamber view, 48 h after heart failure onset. Complete resolution of the MR can be noticed. Download Video 5 via http://dx.doi.org/10.1530/ERP-14-0009-v5 Download Video 5 Video 6 Cardiac MRI after 2 weeks. True fast imaging with steady-state free precession four-chamber view. Normal LV systolic function and no wall motion abnormalities could be observed. Download Video 6 via http://dx.doi.org/10.1530/ERP-14-0009-v6 Download Video 6 Figure 5 Two weeks after acute heart failure onset, no significant changes were noted in the cardiac late gadolinium enhancement imaging. We hypothesize that the cause of the non-apical ballooning syndrome was a combination of esmolol and a preceding stress, due to a GI illness with sympathetic stimulation.

Improvement of ejection fraction after coronary artery bypass grafting surgery in patients with impaired left ventricular function.

ABSTRACTObjectives:The present study evaluates our experience with aorto-coronary bypass grafting in patients with severe dysfunction of left ventricle (LV) and low ejection fraction-EF(<35%). Revascularization of myocardium in this settings remains contraversial because of concerns over morbidity, mortality and quality of life.Material and Methodes:Forty patients with severe coronary artery disease and dysfunction of LV (low ejection fraction <35%) underwent coronary artery bypass grafting in period of 3 years. Preoperative diagnostic of 40 patients was consisted of anamnesis, clinical exam, non-invasive methods EHO, MR and invasive diagnostic methods-cateterization. The major indication for surgery was severe anginal pain, heart failure symptoms and low ejection fraction. Internal mammary artery was used in all operated patients.Results:Average age of patients who have been operated was 59,8. In the present study, 81,3% were male and 18,8% female. We found one-vessel disease present in 2,5% (1/40) of patients, two -vessel disease in 40% (16/40), three-vessel disease in 42,5% (17/40) and four -vessel disease in 15% (6/40) of patients. One bypass grafting we implanted in 2,5% patients, two bypasses in 42,5%, three bypasses in 45 5%, and four bypasses in 10% of patients. Left ventricular ejection fraction assessed preoperativly was 18%-27% and postoperatively was improved to 31, 08% in period of 30 days.Conclusion:In patients with left ventricular dysfunction, coronary artery bypass grafting can be performed safely with improvement in quality of life and in left ventricular ejection fraction.

Neonatal balloon aortic valvotomy for critical aortic stenosis with congestive heart failure and severe left ventricular dysfunction

We present the case report of a 23 day newborn baby who presented with congestive heart failure. On two-dimensional echocardiography, it was diagnosed to have severe (critical) aortic valve stenosis with severe left ventricle (LV) dysfunction with dilated left atrium and left ventricle. Emergency percutaneous balloon aortic valvotomy was performed. Post-procedure the child showed immediate relief of aortic stenosis. Improvement in the left ventricular ejection fraction was also noted. Immediate and short term follow-up shows improvement in the clinical and Doppler echocardiography findings.

Transposition of the Great Arteries

We report the case of a 20-year-old woman with surgically corrected transposition of the great arteries, pulmonary valve defects, and absence of left coronary ostium at a previous cardiac catheterization. Because of worsening dyspnea, she underwent myocardial perfusion PET/CT study with 13N-ammonia at rest and during pharmacological stress, which showed extensive ischemia in the left coronary territory and signs of severe left ventricle dysfunction. Quantitative PET data showed impaired regional coronary flow reserve (<2.0) in the left coronary territory, thus allowing a precise and reliable evaluation of the myocardial perfusion defect because of the absence of left coronary ostium.

Cardiac Resynchronization Therapy Using a Dual Chamber Pacemaker in Patients with Severe Left Ventricular Dysfunction and a Left Bundle Branch Block

Through the use of a dual chamber (DDD) pacemaker, we achieved a cardiac resynchronization effect in a 51-year-old female patient who was transferred to our hospital from another hospital for an operation for three-vessel coronary artery disease. Her electrocardiogram showed a left bundle branch block (LBBB) and a prolonged QRS interval of 166 milliseconds. Severe left ventricle (LV) dysfunction was diagnosed via echocardiography. Coronary artery bypass grafting (CABG) was then performed. In order to accelerate left atrial activation and reduce the conduction defect, DDD pacing using right atrial and left and right ventricular pacing wires was initiated postoperatively. The cardiac output was measured immediately, and one and twelve hours after arrival in the intensive care unit. The cardiac output changed from 2.8, 2.4, and 3.6 L/min without pacing to 3.5, 3.4, and 3.5 L/min on initiation of pacing. The biventricular synchronization using DDD pacing was turned off 18 hours after surgery. She was transferred to a general ward with a cardiac output of 3.9 L/min. In patients with coronary artery disease, severe LV dysfunction, and LBBB, cardiac resynchronization therapy can be achieved through DDD pacing after CABG.

Left ventricle non-compaction cardiomyopathy: Different clinical scenarios and magnetic resonance imaging findings

Left ventricle non-compaction cardiomyopathy is currently considered as a well-defined individual entity. However, it includes a broad spectrum of clinical, radiological and pathophysiological findings. In this review we describe 3 different scenarios of this entity: an isolated case with severe left ventricle dysfunction, an "associated" case in a patient with previous atrial septum defect and pulmonary stenosis and finally, as a finding in a patient with a transient cerebrovascular ischemic attack. In the 2 last cases, both asymptomatic, morphological criteria of left ventricle non-compaction were found but, ventricular function was normal and cardiac-MRI showed no late gadolinium hyperenhancement. Periodical follow-up and familial screening were recommended. Natural history and prognosis factors of this disease are still not well known. Further and longer series of patients with this diagnosis are needed to completely define radiological criteria, clinical presentation and evolution.

What is the exact predictive role of preoperative white blood cell count for new-onset atrial fibrillation following open heart surgery

Background:Atrial fibrillation (AF) occurs in 30% patients on the second or third day post operation; therefore, it is the most prevalent and complicated arrhythmia after open heart surgery. White blood cell (WBC) count seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate the exact relationship between preoperative WBC count and post-Coronary artery bypass graft (CABG) AF in patients with severe left ventricle (LV) dysfunction who underwent elective off-pump coronary artery bypass.Methods:This study was conducted on 104 patients from among 400 patients with severe LV dysfunction undergoing elective off-pump CABG surgery from February 2011 to February 2012, in Afshar Cardiovascular Center, Yazd, Iran. Patients with emergency surgery, unstable angina creatinine higher than 2.0 mg/dL, malignancy, or immunosuppressive disease were excluded. Preoperative serological tests of the participants, such as WBC counts, were saved in their medical dossiers. Of the 400 patients undergoing CABG, AF was found in 54 cases; these 54 male patients formed the experimental group and 60 other patients in the intensive care unit (ICU) and hospital stay without postoperative AF were part of the control group.Results:The average age of the patients was 68.5±12.8 years. WBC counts in patients with and without AF three days before surgery were 12,340±155 and 8,950±170, respectively. On surgical day, WBC counts in the patients with and without AF were 13,188±140 and 9,145±255, respectively (P value three days before surgery: 0.04; P value on surgical day: 0.01). Of the 54 male patients with postoperative AF (POAF), duration of AF was more in cases with elevated WBC count (12,000-14,000) than in those with lower elevated WBC count (10,000-12,000) (]P=0.025), but there was no relationship between frequency of recurrence of AF and grading of elevation of WBC count (]P=0.81).Conclusion:These findings show that three days before surgery and on surgery day, there was a difference in WBC count between both groups. So, preoperative WBC count may predict the incidence and duration of AF; however, it cannot be a predictor of the frequency of recurrence of AF. Finally, WBC count is an independent marker for POAF and duration of AF.

555 Mitral Regurgitation Lesion Type Impacts Outcomes Following Mitral Valve Repair in Patients With Non-Ischemic Cardiomyopathy and Severe Left Ventricle Dysfunction

mmHg for band patients and 5.8 / 2.6 mmHg for ring (P .0001). Mean mitral valve area at rest was 2.3 / 0.6 cm for band and 1.8 / 0.5 cm for ring (P .0001). Exercise duration was 12.9 / 5.7 min for band and 12.6 / 5.7 min for ring (P .78); distance covered was respectively 471 / 77 m for band and 443 / 107 m for ring (P .12). At peak exercise, mean mitral gradient was 10.6 / 4.8 mmHg for band vs 15.3 / 8.2 mmHg for ring (P .0002) while RVSP was respectively 45.8 / 9.5 mmHg for band and 52.6 / 14.2 mmHg for ring (P .004). FMS was present in 17% of band patients vs 55% of ring patients (P .0001). Congestive heart failure (P .05) and atrial fibrillation (P .006) were associated with the utilization of a ring annuloplasty; in addition, ring patients reported lower levels of energy (P .02) and general health (P .007) on their SF-36. Predictors of FMS included ring usage (OR 3.8, 1.3-11.8), smaller resting mitral valve area (OR 9.2, 2.5-33.3) and younger patients (OR 6.9, 2.3-21.5). CONCLUSION: In this first study using full echocardiographic and functional assessment of patients with degenerative mitral valve disease following mitral valve repair, the utilization of a mitral ring was associated with functional mitral stenosis, recurrence of CHF and markers of poorer quality of life. In light of these findings, we have adjusted our techniques and would recommend that careful consideration be given to the selection of an annuloplasty device at the time of mitral valve repair.

Abstract 69: Requirement of Rac1 in Pressure Overload-induced Cardiac Remodeling, and Role of Mineralocorticoid Receptor as a Downstream Pathway

A Rho family GTPase, Rac1, has emerged as an important molecule involved in cardiac remodeling. Some studies demonstrated the requirement of Rac1 in angiotensin II-induced cardiac hypertrophy and diabetic cardiomyopathy in association with generation of reactive oxygen species (ROS). However its role in pressure overload-induced cardiac remodeling is still unclear. On the other hand, we previously reported that Rac1 can activate mineralocorticoid receptor (MR) in cultured cardiomyocytes. Here we demonstrate the requirement of Rac1 in pressure-overload cardiac remodeling, and putative role of MR as a downstream pathway of Rac1. First, we performed sham or transverse aortic constriction (TAC) surgery in C57BL/6 mice, and examined the effect of Rac1 inhibitor ( NSC23766 ) and MR blocker (eplerenone). After 7 weeks, TAC caused severe hypertrophy and dysfunction of left ventricle with significant increase in active form of Rac1. In addition, the amount of MR protein in nuclear fraction, and the expression of some target genes of MR (including serpina3n and serpine-1) in left ventricle were also increased by TAC. NSC23766 significantly reduced the TAC-induced activation of Rac1, and both NSC23766 and eplerenone attenuated cardiac hypertrophy and dysfunction, along with inhibition of MR signaling. Furthermore, TAC significantly increased ROS production in left ventricle, which was also attenuated by both of the pharmacological interventions. We next generated cardiomyocyte-specific heterozygous Rac1-deficient mice (Rac1 CM +/− ) and littermate wild-type mice (WT), and performed Sham or TAC surgery. The TAC-induced hypertrophy and dysfunction of left ventricle were significantly suppressed in Rac1 CM +/− compared with WT (heart/body weight ratio: 6.4 ± 0.86 vs 10.8 ± 0.81 mg/g, ejection fraction 54.1 ± 6.5 vs 33.3 ± 7.3 %, p &lt; 0.05), with inhibition of Rac1 activation. Nuclear translocation of MR protein and increases in expression of the target genes of MR were also significantly attenuated in Rac1 CM +/− compared with WT. These results indicate that Rac1 plays an essential role in the maladaptive cardiac hypertrophy induced by pressure overload, and that MR is an important downstream pathway of Rac1 in heart.

EComment. Coronary artery bypass grafting in left ventricle dysfunction

We read with great interest the article by Jarral et al. concerning the best surgical management in patients with coronary artery disease with left ventricle dysfunction, undergoing surgical revascularization [1]. The authors have reviewed a vast number of published articles. They included in the results of their research 17 studies, comprising of one prospective randomized trial (124 patients), one meta-analysis and 15 retrospective studies. Two additional randomized studies have addressed the question raised by the authors, the Randomized On/Off Bypass (ROOBY) trial [2] and the Coronary Artery Bypass Surgery (CABG) Off or On Pump Revascularization Study (CORONARY) trial [3]. The results of latter publication were fully published recently. In order to be exhaustive, we will summarize the relevant results regarding only patients with left ventricle dysfunction of the above-mentioned studies. The CORONARY trial [3] is the largest prospective, randomized trial involving 4752 patients, conducted at 79 centres in 19 countries. There was no significant difference between off-pump and on-pump CABG with respect to the rate of death, nonfatal myocardial infarction, nonfatal stroke or renal failure requiring haemodialysis at 30 days after randomization. Subgroups analysis showed that there was no significant difference concerning the co-primary outcome in patients (244 patients) with left ventricle dysfunction at one month after randomization (Ejection fraction of the left ventricle between 20% and 34%, Off-pump N = 118 patients and On-pump N= 126, Hazard Ratio: 0.91(0.47-1.74), p= 0.77). In 2009, the ROOBY trial [2] which involved 2203 male patients in 18 Veterans Affairs medical centres, showed no advantage for off-pump CABG either at 30 days or at one year after surgery. There was no significant difference between the two groups in the primary short-term (before discharge or within 30 days after surgery) composite outcome of death or postoperative complications. However, at one year follow-up, patients in the beating-heart technique group experienced worse composite outcomes (death from any cause, repeat revascularization procedure or nonfatal myocardial infarction) than patients in the on-pump group. One hundred and twenty two patients with poor left ventricle function (<35%) were enrolled in this study (Off-pump N = 61 patients and On-pump N= 61) and the authors of this trial clearly stated that the conclusion can be generalized to subgroups of high risk candidates [4], including patients with severe left ventricle dysfunction. It is worth noting that the true efficacy of off-pump CABG could possibly be determined through a longer term follow-up.

Bridge to Transplantation with a Left Ventricular Assist Device

A 61-year-old female patient was diagnosed with dilated cardiomyopathy with severe left ventricle dysfunction. Two days after admission, continuous renal replacement therapy was performed due to oliguria and lactic acidosis. On the fifth day, an intra-aortic balloon pump was inserted due to low cardiac output syndrome. Beginning 4 days after admission, she was supported for 15 days thereafter with an extracorporeal left ventricular assist device (LVAD) because of heart failure with multi-organ failure. A heart transplant was performed while the patient was stabilized with the LVAD. She developed several complications after the surgery, such as cytomegalovirus pneumonia, pulmonary tuberculosis, wound dehiscence, and H1N1 infection. On postoperative day 19, she was discharged from the hospital with close follow-up and treatment for infection. She received follow-up care for 10 months without any immune rejection reaction.

Preoperative C-reactive protein can predict early clinical outcomes following elective off-pump CABG surgery in patients with severe left ventricle dysfunction

Purpose:Atrial fibrillation (AF) is the most common type of arrhythmia following elective off-pump coronary bypass graft (CABG) surgery, occurring on the 2nd or 3rd postoperative day. Postoperative atrial fibrillation and early complications may be the cause of long term morbidity and mortality after hospital discharge. High sensitive C-reactive protein (hsCRP) seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate whether preoperative hsCRP (≥3 mg/dl) can predict post-elective off-pump CABG, AF, and early complications in patients with severe left ventricle dysfunction (Ejection Fraction (EF)<30%).Methods:This study was conducted on 104 patients with severe left ventriclar dysfunction (EF < 30%), undergoing elective off-pump CABG surgery during April to September 2011 at the Afshar Cardiovascular Center in Yazd, Iran. Patients undergoing emergency surgery and those with unstable angina, creatinine higher than 2.0 mg/dl, malignancy, or immunosuppressive disease were excluded from the study. The subjects were divided into two groups: Group I with preoperative increased hsCRP (>3 mg/dl) (n=51) and group N with preoperative normal hsCRP (<3 mg/dl) (n=53). We evaluated post-CABG variables including incidence, duration, and frequency of AF, early morbidity (bleeding, infection, vomiting, renal and respiratory dysfunctions), ICU or hospital stay and early mortality. Data were then analyzed by Analysis of Variance (ANOVA), Chi-square and Fisher exact test for quantitative and qualitative variables.Results:The average age of the patients was 62.5 years, 75 cases (72.1%) were male, and 39 (37.5%) were female. Postoperative AF occurred in 19 cases (18.2%); 17 cases (33.3%) had hsCRP≥3 mg/dl and 2 cases (3.8%) had hsCRP≤3 mg/dl (P=0.03). Postoperative midsternotomy infection, respiratory dysfunction, and hospital stay were significantly higher in group I compared with group N (P<0.05). No statistical significant differences were identified between the two groups concerning other postoperative complications (bleeding, vomiting, renal dysfunction and ICU stay) (P>0.05).Conclusion:Preoperative hsCRP ≥3 mg/dl can predict incidence of postoperative atrial fibrillation and early complications such as midsternotomy infection, respiratory dysfunction, and hospital stay following elective off-pump CABG.

Quality of life in patients with severe left ventricle dysfunction due to coronary artery disease

Abstract

Heart rate turbulence in postinfarction patients with history of malignant ventricular arrhythmias

In the study, there has been retrospectively analyzed heart rate turbulence in postinfarction patients. The cohort of 158 patients consisted of 94 patients with documented ventricular tachycardia and/or ventricular fibrillation (VT/VF) and 64 patients without history of VT/VF. Turbulence onset and slope were calculated from Holter recordings, and left ventricle ejection fraction (LVEF) ≤35% was regarded as severe left ventricle dysfunction. Study groups were similar in age and sex. Left ventricle ejection fraction was lower in the VT/VF group (P < .005). Patients with VT/VF had higher turbulence onset (-0.22% ± 1% vs -0.8% ± 2%; P = .005) and lower turbulence slope (2.6 ± 1.9 vs 4.1 ± 3.5 milliseconds per RR interval; P = .01). These trends were observed in patients with LVEF >35% but not in subjects with LVEF ≤35%. Diabetes mellitus, previous coronary artery bypass graft, and amiodarone therapy have diminished the intergroup differences significantly. Heart rate turbulence is diminished in postinfarction patients with a history of malignant ventricular arrhythmias. It seems to separate subjects at arrhythmic risk among patients with relatively preserved left ventricle function, but it is diminished in patients with previous coronary artery bypass graft, diabetes, and amiodarone therapy.

Use of extracorporeal membrane oxygenator support to salvage an infant with anomalous left coronary artery from pulmonary artery

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a congenital acyanotic heart disease where the left coronary artery (LCA) arises from the pulmonary artery. This results in the LCA receiving blood supply from the low-pressure right ventricle having minimal extractable oxygen. The oxygen delivery to the left ventricle (LV) is severely hampered causing severe hypoxic LV dysfunction early in life. Early surgery prior to serious, irreversible LV dysfunction is the key to survival. Children with ALCAPA usually present in their first few weeks of life, with severe LV dysfunction. After surgical correction of the defect, the myocardium may not recover early from the presurgery myocardial dysfunction. We describe a case where extracorporeal membrane oxygenator was utilized as a means of ventricular support during this critical postoperative period resulting in a favorable outcome.

Papillary Muscle Repositioning in Valve Replacement for Left Ventricular Dysfunction: Ischemic Mitral Regurgitation

The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regurgitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics. We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function. The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p < 0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p > 0.05). The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced.

Current Status of Fetal Cardiac Intervention

The potential benefits of fetal cardiac intervention (FCI) have been realized for many years. In 1975, Eibschitz et al1 reported intrapartum treatment of fetal ventricular tachycardia by administering propranolol to the mother, and as early as 1986, in utero pacing was attempted for complete heart block in a human fetus.2 Recently, however, interest in FCI has accelerated.3–18 As with other fetal interventions,19,20 FCI can only become a highly useful clinical tool if it is applied to conditions in which a feasible mode of therapy is available and either the fetus is at risk for demise as a result of the condition or intervention may alter the evolution of the condition such that the severity of the postnatal disease is substantially reduced (Table 1). For conditions in which the fetus is at high risk for prenatal or neonatal death, the rationale for FCI is obvious, to improve survival. If death is not imminent but the disease is likely to have major lifelong morbidity, the rationale is that FCI will modify the course of cardiac growth, function, and/or development in utero sufficiently to alter postnatal outcome and justify the potential risks of the procedure. Prenatal intervention may also allow the fetus to recover in the supportive in utero environment, during a developmental period when there is enhanced wound healing and the capacity for myocyte proliferation.21,22 View this table: Table 1. Congenital Cardiovascular Anomalies Potentially Amenable to FCI This construct rightfully emphasizes death or significant morbidity as therapeutic targets. FCI can entail substantial short-term risk to the fetus, uncertain long-term risk to the fetus and child, and at least some risk to the mother. There are no known medical benefits to the mother. With that risk profile, FCI will not be embraced by the maternal-fetal medicine and cardiology communities unless it …

Increased plasma levels of osteopontin are associated with activation of the renin–aldosterone system and with myocardial and coronary microvascular damage in dilated cardiomyopathy

In patients with dilated cardiomyopathy (DCM) abnormal myocardial blood flow (MBF) has been associated with coronary microvascular dysfunction. The aim of this study was to test the hypothesis that osteopontin (OPN) plasma levels could be associated with the activation of the renin–aldosterone system (RAS) in these patients and be involved in mediating myocardial and coronary damage. In 66 patients with idiopathic left ventricular dysfunction of variable severity the plasma levels of OPN were correlated with biomarkers of systemic metabolism, RAS activation, myocardial dysfunction and with clinical indexes of left ventricle (LV) function and perfusion obtained by 2D-echocardiography and PET. As compared to controls, patients showed a significant increase of inflammatory markers (OPN: 508 ± 30.8 ng/ml vs. 426.9 ± 16.4, p < 0.05 and interleukin (IL)-6: 1.71 ± 0.29 pg/ml vs. 0.38 ± 0.03 pg/ml, p < 0.001) and of indexes of cardiac damage. OPN levels were significantly correlated with the extent of microvascular dysfunction (MBF at rest: p = 0.01; during dipyridamole: p = 0.0003) and with plasma renin activity (PRA) ( r = 0.26, p = 0.04). Both in patients with milder or more severe LV dysfunction lower MBF values were associated with higher OPN levels and PRA. These results suggest a interdependent role of RAS and vascular inflammation in cardiomyopathy.